IOW Integrated Commissioning Intentions

Introduction IOW Integrated Commissioning Intentions 2017-19 This year as part of the Sustainability and Transformation Plan (STP) development, commissioners and providers have been working collectively to develop plans to improve care and increase efficiency across the region. The Hampshire and IOW CCG commissioners have issued a joint commissioning statement (Appendix A) which reflects the CCG s intent as commissioners across the 8 Hampshire and IOW CCGs. The CCG has also issued its formal notice to the IOW NHS Trust as required by 30 th September (Appendix B, CCG Local Context) In parallel to this, but in alignment to the vision for transformation as set out in the STP, the local IOW commissioners across the IOW CCG and IOW Council (Adult Social Care and Public Health) have produced this local Commissioning Intentions document to set out in more detail the expected commissioning changes for the IOW. This reflects our ambition for integrated commissioning, particularly for community services and national and local requirements. Our aim is to collaboratively manage resources both on the wider STP footprint and also locally for the IOW to ensure we can achieve better outcomes and improvements in health and care services within the resources we have available. Our aim is to deliver the NHS Five Year Forward View (2014) and the requirements of the Care Act (2014). Our focus for 2017-2019 will be on delivery of the NHS Operational Planning and Contracting Guidance, the STP implementation and our local My Life a Full Life transformation agenda, including the deliverables from the Whole Integrated System Redesign. STP NHS LA New Models of Care IOW Integrated Commissioning Intentions for 2017/18 are focused on contractual change and / or service improvement. Our commissioning intentions reflect the different levels of commissioning that are developing across the system. The principle of the different levels is that the focus and delivery is as close to the person as possible, however it is now widely recognised that some of the planning and contracting needs to be undertaken on a bigger scale to drive the level of efficiency that is required to improve outcomes and reduce costs. Page 1 of 18

STP SOLENT ISLAND LOCALITY NEIGHBOURHOOD INDIVIDUAL Our joint local commissioning principles and expectations which reflect STP principles are as follows: Services will be commissioned to be delivered from community settings whenever it is safe and cost effective. Resource allocation will be redistributed to support the focus on prevention and out of hospital care. There will be a continued drive for reduced cost and efficiencies from commissioners and providers. Prevention, early intervention and promotion of self-management opportunities will be a key part of all care pathways and a key component of all service specifications. Use of assistive technology to ensure safe, efficient and cost effective provision will need to be demonstrated as part of all service delivery. All commissioned service providers will be able to demonstrate staff working to the top of their skill set, who are appropriately trained and work in an integrated way. Where there are agreed system wide plans and policies, there will be delivery and adherence. There will be improved data quality and recording to enable the shift to outcome based contracts. There will be an open and transparent relationship between commissioners and providers. All service redesign will be based on the principle of co-production. The attached tables give more specific content to local provision for 2017-2019 but will be further developed in conjunction with providers. Further alignment of commissioned services will be made across related activities to maximise efficiency. Page 2 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT IOW COMMISSIONING INTENTIONS 2017-19 COMMUNITY (INCLUDING PRIMARY CARE AND PREVENTION) KEY PRIORITIES: Transforming Community Services Model Community Nursing Service Discharge Pathways Market Development and Market Management Prevention and Early Intervention Primary Care GP Forward View TO SUPPORT DELIVERY OF: PROVIDERS AFFECTED Transforming Community Services (TCS) Model The transformation of community services will be supported through the development of a shadow Alliance contract for community services in 2017/18 across community health, adult social care and some voluntary sector provision. This is likely to include: PHASE 1 for 2017/18 - Community Nursing, Community Matrons, Continence Service, Falls Prevention, Specialist Nursing, Long Term Social Care, Care Navigators. PHASE 2 for 2018/19 - Building on other commissioned services at Community level, for example Rehabilitation and Reablement, and Local Area Coordinators (Public Health). The aim will be to have this fully operational during 2018/19 as part of the journey towards an MCP Contract by 2020/21. The intention is to support integrated locality working and improve person-centred outcomes. Multidisciplinary Locality Service and Case Management Commission Locality based multidisciplinary services (part of the TCS model) as part of the alliance contract, ensuring effective case management of people with complex conditions. End of Life Care End of Life care will be embedded into contracts where appropriate. The EOLC Strategy will continue to be implemented, with associated pathways and schemes across the whole system, with a specific focus on enabling more individuals to die in their place of choice. Rehabilitation and Reablement There will be a further shift of hospital based rehabilitation to a community rehabilitation model with the procurement of an integrated Community Based Rehabilitation service, leading to integrated health and social care rehabilitation and reablement, including Integrated Locality Teams for the Frailty Rehabilitation pathway. Infection Prevention Control (IPC) Independent Sector care homes and Primary care will be supported to improve infection prevention and control. Wound Care and Tissue Viability Review The intention is to review wound care and tissue viability and commission services including leg ulcer management for both ambulant and house bound patients, tissue viability and options for onward referral. The aim is to improve pathways of care for the management of wounds across Primary care, Secondary care, and specialist services. Costs for wound care will be reduced by establishing an Island formulary for use in Primary Care, appropriate use of FP10s, waste reduction and a process for exceptions. Frailty Service An Integrated Acute and Community Frailty service will be developed and commissioned with consideration of the Rapid Elderly Assessment Care and Treatment (REACT) Model linked to Crisis Response reconfiguration. Page 3 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT Falls The system-wide Falls Strategy will be updated and implemented, including review of the falls pathway and Osteoporosis drugs prescribing. Right Care opportunities will be incorporated to reduce hospitalisation from falls. Proposals for the commissioning of a Fracture Liaison service will be developed. Long Term Conditions The focus will be the achievement of improved health outcomes across all relevant contracts. There will be a shift of management of long term conditions (LTCs) to the community, with support to improve the ability of the workforce to cope with the increasing complexity of need for those with LTCs. Pilots will be set up for those with one LTC (either asthma, heart failure, COPD or neurological conditions) to explore and develop a menu of alternative LTC management options. Wheelchair Service In agreement with the Trust, this service will be re-tendered. As part of the procurement process revised specifications will be developed with tighter access criteria for occasional wheelchair users. Orthotics and Podiatry This will be commissioned as a joint service with a single specification. It is intended that the funding envelope will be reduced through reviewing thresholds for access to the service and avoidance of duplication. Weight Management Tier 1-4 The CCG and Public Health will produce a locally designed and commissioned approach to T1, T2, T3 weight management based on the Family Wellbeing Platform. Additional services to deliver dietary and psychological support will be purchased that integrate into a whole pathway from T1 through T3, and then onward referral into T4. Children and Young People The Children and Young People Transformation Plan will be implemented, with clear pathways, revised service specifications and clear outcomes. A new revised financial envelope will be set and agreed with providers. Market Development and Market Management The LA and CCG will work together to support further market development to create increased opportunity for new providers to enter the market to ensure diversity, improved capacity, quality and choice of community provision. We will work with providers to create the right incentives within contracts to ensure person-centred care, promotion of reablement and retention of independence. Personal Budgets An integrated approach to Personal Budgets will be developed across the CCG and LA, aligned with national guidance, to include market development, with the intention of increasing uptake and streamlining/integrating of business processes and digital routes to market for the individual and their representatives.. Supported Accommodation A strategy with increased options and choice for supported accommodation across the system. Prevention and Early Intervention Prevention and early intervention services will be integrated, with a shift in emphasis to community based services and linked to localities, through different contracting mechanisms, in order to reduce costs and overheads. This will include bringing together services such as: Health visitors, School nurses, Sexual Health, Health checks, Alcohol and Drug treatment. Services will be phased into the new contract as present service contracts come to an end. The intention is to further align contracts. The focus will include diabetes, primary and secondary prevention, improved cancer screening uptake and making every contact count. Page 4 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT Local Area Coordination (LAC), Family Wellbeing Platform (FWP) and Care Navigation Prevention and early intervention services around the individual will be commissioned, with Local Area Coordination and the Family Wellbeing Platform linked into the place services and CYP with Public Health into the locality. The CCG will review the current provision of care navigation to ensure that existing work and new national requirements are aligned; this may require recommissioning of some services PRIMARY CARE Primary Care Sustainability and Transformation The development of primary care provision at scale will be supported with the implementation of the 10 high impact actions to free up GP time. Online Consultation Software in Primary Care General practice online consultation software will be implemented over a two year period. 7 Day Primary Care Services 7 day primary care services will be commissioned in 2017/18 to improve access to routine and urgent primary care services. This intention needs to be cross referenced with the development of urgent care pathways. Development of Locality Hubs and Neighbourhoods The CCG will continue to develop its plans for 3 locality hubs as part of the One Public Estate agenda with a view to moving three projects forward in Newport, Sandown and Brighstone. Training for Reception and Clerical Staff The CCG will develop and deliver a programme of work on active signposting and document management in primary care, with a view to releasing GP capacity in primary care. (Part of the Time for Care Programme). Workforce Development The CCG will support further use of clinical pharmacist roles in primary care. This is intended to release GP capacity and improve medicines management in primary care practices, improving clinical and cost effectiveness. Recommission Anticoagulation and Phlebotomy Services The CCG will finalise arrangements to recommission anticoagulation services with a single provider and complete a tender for primary and community care phlebotomy services on a similar basis. Implementation of Hampshire Health Record The CCG will support the implementation of the Hampshire Health Record across primary and secondary care, enabling sight between primary and secondary care records both on and off island. Roll out access to online health services including Repeat Dispensing and e-referral The CCG will develop a programme of work to encourage both professionals and the public to utilise existing electronic and on line services to book appointments, view records and order prescriptions. Medicines Optimisation in Primary Care The intention is to optimise the quality, safety and value for money treatments, medicines and devices prescribed by GP Practices on the Isle of Wight to improve patient safety, patient experience and cost effective services. Review Non-PBR Drug Cost Non PBR drug costs will be reviewed to manage expenditure. Stoma Care Service Based on Formulary The Stoma care service will be reviewed to ensure that it is cost effective and evidence based. Page 5 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT Reduce Antibiotic Prescribing in Primary Care Antibiotic prescribing in Primary Care will be reduced to improve antibiotic stewardship and cost containment/savings. Healthcare at Home Healthcare at home provision will be regularly reviewed to ensure that it is in line with national guidance. Development of micro-suction service in primary care The CCG will review the volume and costings associated with the delivery of micro-suction with a view to creating a community service. MENTAL HEALTH SERVICES KEY PRIORITIES: Transformation of Mental Health Services Delivery of Constitutional Targets Supporting the Development of the MH Alliance Delivering the Transforming Care Agenda Improving Access to Mental Health Services for Children and Young People Learning Disabilities The Transforming Care Agenda for people with LD, Autism, Autistic Spectrum Disorder and/or Challenging Behaviours will be embedded within Health & Social Care Services, with clear pathways, revised service specifications and clear outcomes (data reporting). A new revised financial envelope will be set and agreed with providers. Mental Health Mental health services will be reviewed and recommissioned, with clear pathways, revised service specifications and clear outcomes. A new revised financial envelope will be set and agreed with providers. Encouragement and support will be given to increasing partnership with the voluntary sector as part of service redesign. Focus will be on: Improved single point of access 24/7 Increased access to psychological therapies for people with severe mental illness Safe Haven (Crisis Café) Personality Disorder services for people with complex needs. Dementia The Dementia Pathway will be reviewed and recommissioned, inclusive of a future model for an Assessment Treatment Unit (Shackleton), within a revised financial envelope. Mental Health Alliance The mental health alliance will be supported across the STP for access that would benefit from a STP wide approach, including PICU inpatient services (AMH and OPMH), crisis care (AMH and OPMH) and rehabilitation. Delivery of acute provision will be transformed so that as many people as possible are provided with care closer to home and are supported to live independently. Accountable payment approaches will be developed, which ensure that payments are linked to quality and outcomes. Child and Adolescent Mental Health Services Delivery of the Children and Young Peoples plan specifically improves 24/7 access to specialist advice, improved access to psychological therapies and improved access to eating disorder support and treatment. Page 6 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT PLANNED CARE KEY PRIORITIES: Sustainability of Acute Services Delivery of Constitutional Standards Transformation of Outpatients Sustainability of Acute Services Phase 1: Urology Strategic options will be developed for services that are no longer sustainable in their current form as identified by the local sustainable services review and the STP Solent Acute Care Alliance. The Urology review will be implemented and commissioned through the Solent Alliance of providers, retaining activity on Island where clinically safe to do so, where good patient outcomes can be demonstrated, and where it is cost effective. Phase 1: Cancer Oncology Implementation of the recommendations from the CCG/NHSE Specialised Commissioning Cancer Oncology Review. Consideration of alternative service delivery model for the isle of Wight. This will also require exploration of innovative ways of delivery partnership working across hospital providers. Sustainability of Other Acute Island Services Clinical reviews of other acute services will be supported through the Solent Alliance to develop appropriate models of provision. Services will be recommissioned as agreed through this partnership working. The intention is to retain activity on Island where it is clinically safe to do so, where good patient outcomes can be demonstrated, and where it is cost effective. Outpatients Outpatient contracts will be reviewed across all specialities to ensure every outpatient contact adds value to patient outcomes and that face to face appointments are only given where clinically necessary and by the most appropriate person. Ophthalmology The local community eye service will be developed, which will include procurement and mobilisation. Procedures of Limited Clinical Value Utilising data from NHS Right Care Programme, Commissioning for Value, the CCG will explore further potential for referral refinement to reduce unwarranted clinical variation and procedures of limited clinical value. Diagnostics Non-payment for repeat tests deemed unnecessary will be considered. Maternity The CCG will support the delivery of Better Births. Procurement- Dermatology A market re-test via open engagement will commence in quarter 4 2016-17, in order to establish if competition exists to consider running a competitive procurement. Page 7 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT URGENT CARE KEY PRIORITIES: System Resilience and the Achievement of Constitutional targets Co-ordinated Urgent Care Pathways Default Ambulatory Care System Resilience and the Achievement of Constitutional Targets The key focus will be on delivery of system resilience schemes to match capacity to predicted demand, ensure care pathways focus on the prevention of admission and the facilitation of discharge, the achievement of the Emergency Department, Ambulance and 111 standards and reducing costs across the system. Co-ordinated Urgent Care Pathways Current contracts and service specifications will be reviewed to ensure that they reflect the implementation of the national Transforming Urgent and Emergency Care programme Safer Faster Better good practice (including Integrated Urgent Care Standards), and the IW Urgent and Emergency Care Strategy to: - Deliver default Ambulatory Care services. - Build alternatives in primary care to better manage, on the day urgent care primary services demand including locality based care. - Implement next stage of the Urgent Care Service including primary care service sustainability and delivery of 7/7, integrated urgent care response services (including 111, ambulance, clinical hub and digital access) and further integration of the hospital based urgent and emergency care to create an urgent care floor incorporating Emergency Department, Out of Hours, Medical Assessment Unit and Ambulatory Care. - Develop workforce skill mix to maximise efficiency. - Ensure appropriate use of urgent care services including 999, 111, Primary Care and promoting Self-Management. Ambulance Consideration of a Review of the sustainability of a stand-alone ambulance service due to current performance issues. Patient Transport Service (PTS) The PTS contract will be reviewed to ensure value for money. Paediatric Assessment Unit (PAU) A Paediatric assessment unit will be commissioned, to ensure timely assessment by paediatric specialists and avoid unnecessary admissions. The PAU will be supported by a robust community paediatric nursing service who will support Children and Young People and their families in community settings. This will improve safety, reduce re attendances and provide families with a much improved service in the community and their own homes. Primary care will work more closely with the acute service with increased communication, shared pathways and an ability to refer children for periods of observation. Page 8 of 18

STP WISR / MLAFL RIGHT CARE CCG IAF 5YFV OTHER-CCG -LA IOW NHS TRUST PRIMARY CARE L. AUTHORITY VOLUNTARY INDEPENDENT OVERARCHING Thresholds Review of current commissioned service and then thresholds against guidance will be undertaken to ensure most appropriate clinical needs are met within available resources. A rolling programme of reviews will be developed. Assistive Technology The system-wide 5 year Technology Enhanced Care(TEC) Strategy, currently in development, will be implemented, including review / recommissioning of TEC services, with ongoing monitoring and evaluation of agreed milestones and any ongoing pilots. Integrated Access - Single Point of Access Extending the hub to include the prevention, early intervention and totality of what person needs on first contact. Page 9 of 18

Appendix A Hampshire & Isle of Wight CCGs STP Joint Commissioning Intentions Statement Commissioners and Providers across Hampshire and the Isle of Wight (HIOW) have been working collectively to develop a Sustainability and Transformation Plan (STP) for the region. The granular plans for the STP are still being developed but there is intent to describe within the STP; investments, savings and a control total that will be delivered within the region over the next five years. Commissioners therefore signal their intention to commission the plans as described in the STP, together with the nine must do priorities outlined in the recent Operating and Contracting Guidance 2017-18 and will work with providers to complete this to the level of detail required for contracting over the coming months. Commissioners trust that the work we have been doing collectively on the STP will ignite a new way of working with partnership behaviours becoming the norm, and where all partners are equally committed to delivering the system control total. Commissioners wish to adapt contractual arrangements to support the success of the STP, with a focus on improving quality and maximising the health and wellbeing of our population and our use of resources. It is no longer sustainable for us to continue to pursue traditional ways of contracting and we intend to change our contractual arrangements to eliminate the extremes in current contracting arrangements (e.g. block, PbR). In time, this is likely to include moving to alternative forms of contracting to support the implementation of new models of care, such as MCP, PACS or alliance contracts, which are based on population and outcomes. Our system will not deliver the required productivity savings in silos, and we aim to improve and invest in preventative, primary and community care, engaging with our patients and communities, working with social care and wider services to support improved productivity and quality as well as people s well-being. Our system recognises that strengthening and transforming general practice will play a crucial role in the delivery of the STP plans, and is committed to implementing the General Practice Forward View. These intentions should be read in conjunction with NHS England s strategic and operational planning guidance and the NHS Standard Contract. Contracts will be based on the following principles: our system aims to spend less time locked in adversarial and transactional relationships and we will contract with the following principles:- Contractual arrangements will be developed to support the successful implementation of our plans and the STP, deliver the expectations of the 5YFV, drive improvements in health and care, restore and maintain financial balance, and deliver core access and quality standards. In delivering the STP plans there will be a reshaping of resource allocation with a focus on investment in out of hospital services, within system resources, and a relentless focus on efficiency. Incentives will be re-aligned across providers and commissioners accordingly, with an emphasis on overall system cost reduction and a collective approach to reducing and managing risk. Contractual incentives for collaborative working will be introduced. Page 10 of 18

Contracts will be agreed that support the transformational change plans required, do not exceed the overall affordability of the STP, and are in keeping with the activity parameters set out in the STP. Contracts will be set that reflect the required financial improvement trajectory within the STP and no contract will be agreed that worsens the overall financial health of HIOW. Accordingly, a system approach to achieving the financial control total for HIOW will be developed, with a supporting risk management framework. The risk management framework will be used encourage a new approach to contracting with coproduction and an open book approach to manage costs within system resources. Contracts will underpin a common set of standards and common expectation of patient experience for our population. Commissioner approach: commissioners will work in an alliance to commission at scale, ensuring a common commissioning and contracting approach, based on clear principles (as set out above). Contracts will be developed and agreed across Hampshire and the Isle of Wight (HIOW) in a standardised way, thereby avoiding the need for multiple and protracted negotiation processes. Commissioners aim to develop a single contract with providers and/or the emerging alliances, and may move to lead provider contracts for agreed pathways to support the emerging horizontal integration plans (e.g. vascular). The alliance structures are being developed in the STP to drive quality improvement, to standardise care processes and outcomes for our citizens, to foster collaboration, reduce costs, strengthen resilience and deliver constitutional standards. Where alliances are formed in 2017/18 it is anticipated that the contract will remain with the statutory provider, but the execution of the contract (or elements of) will be undertaken collectively with contract discussions happening once across HIOW on activity, performance, quality and outcome indicators. It is expected in this process that variation in utilisation rates and outcomes identified through the atlas of variation, right care and other CCG benchmarking exercises will be reduced year on year, and contracts will reflect, in year one, movement towards this standardisation. The initial focus for collaborative contracts will be on specialised and acute elective care. Commissioning Intentions: in 2017/18 and 2018/19 and beyond we seek to develop services collaboratively to manage resources within that available to the system and will work with providers in delivering the nine must do priorities as described in the 2017-2019 NHS Operational Planning and Contracting Guidance, and in particular improving the following:- Outpatient efficiency: optimise the use of acute outpatient resources. Focus on first appointments avoided through advice and guidance or moved closer to home in the community or through the use of technology. Ensure that follow-up appointments become an exception, and where they are necessary they are patient-initiated or follow an agreed pathway. Local payment reform will be considered to compliment the redesign of first outpatient appointments, and the reduction in in inappropriate outpatient follow-ups. There will be a consistent approach across HIOW. Reducing length of stay for planned care, and associated costs for the system: as a health community we expect patients to be treated at the lowest level of intensity, with the order of priority for planned care as follows: Page 11 of 18

To be treated outside of an acute setting wherever possible. If an acute setting is required, to be treated without admission i.e. as an outpatient. Where admission is necessary, treatment as a day case as the first consideration. If day case treatment is not appropriate, discharge at the earliest opportunity facilitated by robust discharge planning. Reducing length of stay for non-elective care, and associated costs for the system: as a health community we will work to ensure that patients stay in an inpatient setting for the minimum number of days possible, improving patient experience and outcomes, and will commission for the plans emerging from the flow and discharge STP work stream. We will also benchmark length of stay in critical care, and review the process for reporting activity. Ambulatory Care: the system will work together to ensure that conditions sensitive to ambulatory care (ACSC) are managed in primary and community care, reducing admissions for ACSC to secondary care. Ambulatory Emergency Care (AEC): all patients presenting in emergency departments should be considered at the outset for ambulatory emergency care, with the aim of reducing length of stay in the department, and avoiding admissions for the majority of patients treated through an AEC approach Working across provider and commissioner organisational barriers : we will identify and address areas where our individual organisational forms may prevent maximum efficiency, including but not limited to: Reviewing high cost drugs and devices which are managed by providers and paid for by commissioners on a pass-through basis. Prescribing in primary care, secondary and tertiary settings. Viewing pathways for services from a system perspective which fall to separate commissioners, e.g. critical care; cancer; mental health; neo-natal services. Ensuring appropriate planned treatments for patients: work together to ensure that planned care treatments are the most efficacious for the patient, and that where clinical evidence exists to support the restriction of certain procedures or treatments (either in general or for certain patient groups where outcomes will not be optimised) these treatments or pathways will not be routinely available. Diagnostics: we will collectively agree how patients will have access to diagnostics without duplication or avoidable delay, streamlining services to improve access and reducing cost to the wider system. Optimising use of NHS resources: commissioners and providers will work together so that as capacity changes across the system, resources are used to the best effect for the wider health community, either through re-deployment, or use for agreed alternative pathways, or through cost reduction for the wider system. Commissioners will support, where robustly evidenced, the emerging plans for new models of care and prevention for adults and children, and reinvest system resources to enhance; prevention, independence and self-care, fully integrated primary care, integrated intermediate care, complex care and end of life care, and pathways for long term conditions. Transforming care plan: commissioners will continue the work in implementing the transforming care plans for patients with learning disability, and aim to reduce the reliance on inpatient care and move to community supported care where possible. Page 12 of 18

Mental health: Commissioners will support, within the available resource, the plans in the STP to; develop the alliance, redesign and transform services to support early diagnosis and improved access to evidence based care, redesign and transform acute and community services including PICU, inpatients services (adult mental health and older peoples mental health), crisis care and rehabilitation, and the workforce redesign. Commissioners also wish to explore further opportunities for transforming children s mental health services, including taking forward the delivery of Future in Mind Local transformation plans, and reviewing crisis care options for children with mental health problems. Prevention: Commissioners will support the ambition in the 5YFV to upscale the work on prevention and will work with providers to take forward the plans being developed as part of the STP, these will include:- Ensuring Making Every Contact Count is embedded in organisations Identification and signposting for relevant lifestyle risk factors, e.g. obesity, diabetes, smoking and respiratory Implementing Government Buying Standards for food and catering services Urgent and Emergency Care: During 2017/18 commissioners will progress the development of a clinical hub that supports NHS 111, 999 and out hours calls as outlined in the STP plan. We will, working with the ambulance service and new care models, look to see a reduction in the proportion of ambulance 999 calls that result in an avoidable transportation to the ED department. Cancer: Commissioners wish to ensure that progress is made in improving one year survival rates by delivering a year on year improvement in the proportion of cancers diagnosed at stage one and stage two and reducing the proportion of cancers diagnosed following an emergency admissions. Local baselines will be set for each system to monitor progress. Commissioners wish to ensure that:- All patients have a holistic needs assessment and care plan at the point of diagnosis. A treatment summary is sent to the patients GP at the end of treatment. A cancer care review is completed by the GP within 6 months of a cancer diagnosis. Digital HIOW have developed a Digital Roadmap and are committed to improving efficiency and patient care through the development of our digital systems. We will work with providers to implement the roadmap, and the plans in the operating guidance, including the mandated use of the e-referral system to ensure full compliance by April 2018. Performance Delivery: all providers will be expected to deliver the constitutional and national standards. Baseline trajectories will be the agreed trajectories for 2016/17. Any provider whose plan for 2016/17 did not achieve one or more of the national standards for operational performance will not be able to reduce this baseline and will have to reach the national standards during 2017/18. Quality In making quality everybody s business and in support of the delivery of consistently high quality care, providers, commissioners and other key stakeholders intend to work in close partnership to provide strategic leadership for the development of an integrated and collaborative approach to quality governance across the entire Hampshire and Isle of Wight footprint. We aim to pursue a relentless Page 13 of 18

drive for improvement, informing and influencing new and emerging modules of care under the HIOW Sustainability and Transformation Plan and the HIOW Vanguard programmes. The programme of transformation across HIOW presents clear opportunities for health and social care organisations to work together to reform current quality challenges. The approach will aim to deliver: A more streamlined and efficient approach to quality measurement and monitoring. A robust process for determining the quality impact and risks arising from reconfigured services under the STP and vanguard programmes. Opportunities to increase the patient/carer voice in defining, measuring and evaluating the quality of services. Clarity and alignment for the quality requirements in local outcomes based contracts. Reduction in quality variation across the entire patient pathway rather than in silos. The structure, process and guidance needed by teams working on new models of care to ensure regulatory compliance. Ensuring quality arrangements reflect cross border provision and commissioning. Delivery of a system wide approach to quality measurement. Better information from data, including the effective triangulation of multiple sources of data and quality surveillance that focuses on early warning and prevention rather than multiple investigations after the event. Hampshire/Wessex/national benchmarking for quality improvement and outcomes. New provider/commissioner alliances and configurations which will support reconfigured services and organisations e.g. accountable care systems. A real focus on health gains, linking quality to population health outcomes in new and innovative ways. Agreement on the approach to defining, measuring and monitoring quality which will be required under new contractual arrangements. Engage and influence regulatory assurance processes (NHSI/NHSE and CQC). Driving learning and the spread of best practice across the STP footprint. New approaches to quality governance will be developed in the early part of 2017/18, whilst the latter part of the year will focus on rapid implementation and spread. There is an intention to fully align quality contract requirements and schedules across all HIOW commissioners in 2017/8 and to ensure CQUIN and other incentive schemes for quality deliver tangible improvements for patients, including using resources flexibly to support transformation. To ensure the quality resource is directed at transformation and improvement, more contractual requirements for quality will be reportable through the information schedule with escalation to CQRM when KPIs deteriorate. This will mean that quality schedules focus on a smaller quality improvement priorities in a deeper way, which will aim to yield sustained improvements. Page 14 of 18

Counting and Coding Commissioners seek to contract to the principles outlined in this letter, however, whilst the detail for how these principles map into a different contracting approach is being worked through with providers, commissioners have a requirement to issue counting and coding intentions for 2017/18. The STP commissioners have worked through a number of collective intentions as well as issuing local intentions for 2017/18. Commissioning of Specialised, dental health and public health During the 2017/18 contract round commissioners aim to work collaboratively with our colleagues in specialised and public health to develop services from a system approach. Details of the commissioning intentions for dental and public health which are commissioned by NHS are have been issued separately Details on specialised commissioning have been issued separately. Page 15 of 18

Local Context for Commissioning Intentions Appendix B The CCG wholly support the direction of the STP as detailed in the covering letter, in turn we will be setting out our aligned detailed local Commissioning Intentions by 30 th October. Our commissioning intentions are set in the context of the extensive transformation agenda that our system has committed to and the challenging financial position of the CCG, Trust and of the health systems of which we are part. We aim to embrace change at pace and to explore every opportunity to creatively utilise the commissioning funds available to us, and contract with you for services going forward in a way which increases the quality and safety of services for patients, drives us towards the goal of co-ordinated and integrated services, and gets as much out the Isle of Wight commissioning spend per pound as possible. Our objective is financial sustainability for all partners within our health economies, recognising that this will mean greater co-operation and collaboration across organisations to identify initiatives which will bring greatest benefit. Therefore, the CCG will continue to use the contracts with providers to contribute to the transformation of local health and social care services to implement the Health & Wellbeing Board Five Year Health & Social Care Vision for the Isle of Wight. We support the models of care jointly developed by the IOW health & care system through the Vanguard application and our intentions will reflect that. Key Initiatives developing as part of the New Models of Care and System Resilience Strategies will drive commissioning decisions throughout the next 2 years. These include the Whole Integrated System Redesign along with its 6 priority areas, MLAFL work stream development, STP progress, Turnaround recommendations, Cost Base Reviews, System Estates Strategic review, the System Wide Digital Roadmap / Interoperability Programme, Primary Care Strategy, Joint commissioning with the local Authority and other schemes developing as part the new models of care work. Where outcomes are known these are reflected in our intentions. Where further outcomes, recommendations and agreements emerge we will expect to implement appropriate actions during the contract period by working with you in partnership. As part of the new models of care programme we also expect to continue exploring with you how new types of contract can be implemented in future years to drive delivery of services in the direction of travel, and agree principles and timetables to move to other contracting methodologies. This may involve a move to Outcomes-Based Incentive Contracts and/or to implement a form of provider alliance contract, bringing together a range of providers currently delivering community services into a single contract with us, with common Key Performance Indicators and payment incentives, underpinned by the Better care Fund. As we move towards the full integration of both health and social care services, in some cases as new opportunities for improvement are developed the operation of a Shadow Period for the operation of the contract may be appropriate. This will require careful joint planning and involve robust data collection and monitoring exercises, particularly for activity and outcomes. We will work with you pre and post contract to develop these programmes. Page 16 of 18

Consideration will also be given in year to the future contractual model for the integrated services and any transfer of services to the agreed model. Recognising that contractual amendments are expected in relation to the development of the IOW health system s new model of care, and in order to help facilitate this, it is the intention that there will be a clear separation of the main contract components including Acute and Community, Mental health and Ambulance. This will enable a more transparent approach to developing robust new models and contracts. It will be necessary to agree the depth and type of data required through any shadow periods. The CCG is a significant outlier in relation to its Mental Health expenditure and therefore we will be seeking a reduction in mental health costs through reconfiguration of services and benefits developed through the mental health alliance. These will be negotiated and agreed with you. We are both, of course, extremely aware of the system-wide capacity issues experienced in the last year, and in particular the deterioration in the Trust s performance in relation to key NHS Constitution targets. We will therefore be placing high emphasis on System Resilience related improvement plans that support return to achievement of these targets, particularly the Ambulance and A&E targets, as well as supporting the RTT Incomplete target and waiting list reduction. This may involve amendment to specifications and budgets in year and the CCG would expect the Trust to comply with associated contractual amendments without adherence to notice periods, where actions are mutually agreed. Given the pressures on performance it is our intention to review the Indicative Activity Plan and to undertake a more extensive Demand and Capacity Planning review exercise in collaboration with you. Arrangements for this process will be agreed via the Officer Level Meetings. This will form the basis of the revised Indicative Activity Plan for 2017-18. It will be essential that the provider plans demand and capacity to ensure sustained achievement of the 18 Weeks Referral to Treatment Target (RTT) and other NHS Constitution Targets. We will be reviewing the Local Quality Requirements to ensure that CCG concerns, are incorporated. The CCG will also be considering the progress of current action plans, we will be looking to ensure that the Trust can demonstrate compliance against policies and appropriate investment in a workforce to deliver its statutory requirements and in particular those that support the CCG. We will agree with the Trust any further amendments to contractual clauses which reflect the quality improvements required. Page 17 of 18

ALIGNMENT WITH NATIONAL AND LOCAL PRIORITIES Appendix C Five Year Forward View 9 Must Dos : Primary Care - Implement Primary Care GP Forward View Urgent and Emergency Care - A&E Improvement Plan, 4 standards for 7DS, Waiting time standard RTT and Elective streamline pathways including outpatient redesign to reduce follow ups, Maternity services review. Cancer pathways for Breast cancer rolled out, Recovery Package commissioned Mental Health IAPT access, CYP IPAT, NICE guidance re 2 week referrals, Individual placements, CYP access to eating disorder treatment, Reduce suicide rates by 10% Learning Disability reduce premature mortality by improving access to services Improving Quality in organisations STPS implementation of milestones and achievement of trajectories Finance Deliver CCG & Provider control totals and achieve local system financial control totals. STP 6 Core Programme New Models of Integrated Care Solent Acute Alliance Mental Health Alliance Effective patient flow and discharge Prevention at scale North and Mid Hampshire configuration IOW CCG Improvement and Assessment Framework Priorities: Top Priorities Cancer E-referral Constitutional targets NHS Continuing Healthcare Secondary Priorities Diabetes Education Obesity in Children Maternal smoking LD Annual Health checks Choices in Maternity DTOCs attributable to Healthcare IOW CCG Right Care Priorities: Respiratory Mental Health Musculoskeletal Endocrine Genitourinary Cancer Circulation Page 18 of 18